HomeMy WebLinkAboutAPPLICATION FOR EXTENSION DENIED SWG2023-00034 - SWG Inactive - 5/4/2026 Pen/eo(
(jj• • MASON COUNTY 415 N 6T"STREET, SHELTON WA 98584
SHELTON:360-427-9670, EXT.400
Public Health & Human Services BELFAIR:360-275-4467, EXT.400
APPLICATION FOR EXTENSION IIt V y��I
Amount Paid: hi
Receipt Number: c t to- 1 MAY t14 2U
Instructions: Applicant to complete Parts 1 and 2 and septic designer/engineer PAGM'T
Part 3. Submit application with extension permit fee. Make check payable to Mason County
Treasurer. Staff will review your application and determine if the extension can be approved.
Conditions for approval are outlined in this application.
Prior to or after expiration of an approved design, the applicant may apply for a permit
extension. The permit extension shall extend the expiration of the design for up to two years,
but not exceed five years from the signature date of the Environmental Health Specialist's
site inspection{Per WAC 246-272A-200(4)(e)}
All approved septic designs may receive one extension. Additional extensions shall not be
accepted and would instead require a renewal.
PART 1: APPLICANT AND PARCEL INFORMATION
Name of Applicant: 'o f c Phone: S 60-q% 1-
Mailing Address of Applicant: Day m/oi
City: i l/Y VI State: 144' Zip:
12-digit Tax Parcel Number: 3a 13 --7S'O0 o 5 O
Site Address: AGO E1 sake !QcI
Permit Number: SWG 10,13- O00 3`l
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
This form may be scanned and available for public view on the Mason County Web site.
Page 1 of 2
PART 3: ORIGINAL DESIGNER/ENGINEER REVIEW AND APPROVAL
I, the undersigned original Designer/Engineer, attest that I have reinspected the property and
found the following conditions to be true as of the date of my signature below:
• NO part of the proposed Drainfield or Reserve area has been altered or disturbed in such
a way that may render the proposed design invalid.
• NO development has occurred on this parcel or neighboring parcels which would cause
the proposed system to no longer meet minimum setbacks,.
• NO Boundary line adjustments or subdivisions have occurred which would cause the
property to fall below the minimum land area requirements of WAC 246-272A.
IDesigner/Engineer Stamp:
Signaturfof Desig er/ ngineer Date
I LICENSED 91GNER
EX
PIRES 12115! L,
Comments/Conditions: — — — — — — — —
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
Extension Denied
Extension Approved New Expiration Date: _
Comments:
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W a$ /)O'f Qpft ro of t SSU ee( . £�rf / ifi G'ia.' .
Enviro ntal Health Specialist Signature:
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is form may be scanned and available for publl" w on ffl44ason County Web site.
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